Objective
Fluid overload is a common phenomenon seen in intensive care units (ICUs). However,
there is no general consensus on whether continuous or bolus furosemide is safer or
more effective in these hemodynamically unstable ICU patients. The aim of this meta-analysis
was to examine the clinical outcomes of continuous versus bolus furosemide in a critically
ill population in ICUs.
Data Sources
MEDLINE, EMBASE, PubMed, and the Cochrane Database of Systematic reviews were searched
from their inception until June 2017.
Review Methods
All randomized controlled trials, observational studies, and case-control studies
were included. Case reports, case series, nonsystematic reviews, and studies that
involved children were excluded.
Results
Nine studies (n = 464) were eligible in the data synthesis. Both continuous and bolus
furosemide resulted in no difference in all-cause mortality (7 studies; n = 396; I2 = 0%; fixed-effect model [FEM]: odds ratio [OR] 1.15 [95% confidence interval (CI)
0.67-1.96]; p = 0.64). Continuous furosemide was associated with significant greater
total urine output (n = 132; I2 = 70%; random-effect model: OR 811.19 [95% CI 99.84-1,522.53]; p = 0.03), but longer
length of hospital stay (n = 290; I2 = 40%; FEM: OR 2.84 [95% CI 1.74-3.94]; p < 0.01) in comparison to the bolus group.
No statistical significance was found in the changes of creatinine and estimated glomerular
filtration rate between both groups.
Conclusions
In this meta-analysis, continuous furosemide was associated with greater diuretic
effect in total urine output as compared with bolus. Neither had any differences in
mortality and changes of renal function tests. However, a large adequately powered
randomized clinical trial is required to fill this knowledge gap.
Key Words
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of Cardiothoracic and Vascular AnesthesiaAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Fluid overload in the ICU: Evaluation and management.BMC Nephrol. 2016; 17: 1-9
- Fluid accumulation, survival and recovery of kidney function in critically ill patients with acute kidney injury.Kidney Int. 2009; 76: 422-427
- A positive fluid balance is associated with a worse outcome in patients with acute renal failure.Crit Care Med. 2008; 12: R74
- Fluid resuscitation in septic shock: A positive fluid balance and elevated central venous pressure are associated with increased mortality.Crit Care Med. 2011; 39: 256-265
- Fluid balance and weaning outcomes.Intensive Care Med. 2005; 31: 1643-1647
- Continuous infusion versus bolus injection of furosemide in critically ill patients.A meta-analysis. Signa Vitae. 2011; 6: 58-63
- Loop diuretics in clinical practice.Electrolyte Blood Press. 2015; 13: 17-21
- Continuous infusion of loop diuretics in the critically ill: A review of the literature.Crit Care Med. 1994; 22: 1323-1329
- Frusemide administration in critically ill patients by continuous compared to bolus therapy.Nephron Clin Pract. 2007; 107: 70-76
- Short and long-term effects of continuous versus intermittent loop diuretics treatment in acute heart failure with renal dysfunction.Intern Emerg Med. 2015; 10: 41-49
- Goal-directed diuresis: A case control study of continuous furosemide infusion in critically ill trauma patients.J Emerg Trauma Shock. 2015; 8: 34-38
- Continuous infusion or bolus injection of loop diuretics for patients admitted for severe acute heart failure: Is one strategy better than the other ?.Rev Port Cardiol. 2015; 34: 95-102
- A prospective, randomized study to evaluate the efficacy of various diuretic strategies in acute decompensated heart failure.Indian Heart J. 2014; 66: 309-316
- Determinants of response to furosemide in normal subject.Br J Clin Pharmacol. 1977; 4: 121-127
- Acute tolerance to furosemide diuresis in humans.J Pharmacol Exp Ther. 1985; 233: 447-453
- Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015.BMJ. 2015; 349: g4647
Bansal N. Measuring fluid overload and mortality risk in ESRD patients. Medscape. Available at: https://www.medscape.com/viewarticle/881332. Accessed November 28, 2017.
- Estimating the mean and variance from the median, range, and the size of a sample.BMC Med Res Methodol. 2005; 5: 1-10
- Recommendations for examining and interpreting funnel plot asymmetry in meta-analyses of randomised controlled trials.BMJ. 2011; 343: d4002
Ryan R, Hill S. How to GRADE the quality of the evidence. Cochrane Consumers and Communication Group. 2016. Available at: http://cccrg.cochrane.org/author-resources. Accessed November 27, 2017.
- Diuresis with continuous infusion of furosemide after cardiac surgery.Am J Surg. 1983; 146: 796-799
- Protocol guided diuretic management: Comparison of furosemide by continuous infusion and intermittent bolus.Crit Care Med. 1997; 25: 1969-1975
- Frusemide in pulmonary edema: Continuous versus intermittent.Clin Intensive Care. 1997; 8: 273-276
- Comparison of hemodynamic and biochemical effects of furosemide by continuous infusion and intermittent bolus in critically ill patients.J Infus Nurs. 2004; 27: 255-261
- Positive fluid balance is associated with poor outcomes in subarachnoid hemorrhage.J Stroke Cerebrovasc Dis. 2015; 24: 2245-2251
- Positive fluid balance and prognostic factors of ICU mortality in patients admitted with septic shock.Crit Care Med. 2014; 18: P70
- Diuretic therapy and resistance in congestive heart failure.Cardiology. 2001; 96: 132-143
- Clinical pharmacology of loop diuretics.Drugs. 1991; 41: 14-22
- Loop diuretic strategies in patients with acute decompensated heart failure: A meta-analysis of randomized controlled trials.J Crit Care. 2014; 29: 2-9
- A meta-analysis of continuous vs intermittent infusion of loop diuretics in hospitalized patients.J Crit Care. 2014; 29: 10-17
- Continuous infusion versus bolus injection of loop diuretics in congestive heart failure.Cochrane Database Syst Rev. 2004; 1 (CD003178)
- Continuous infusion versus intermittent bolus furosemide in ADHF: An updated meta-analysis of randomized control trials.J Hosp Med. 2012; 7: 270-275
- Continuous infusion versus bolus injection of furosemide in pediatric patients after cardiac surgery: A meta-analysis of randomized studies.Signa Vitae. 2012; 7: 17-22
- Continuous infusion versus intermittent bolus injection of furosemide in acute decompensated heart failure: A meta-analysis of randomised controlled trials.Anaesthesia. 2018; 73: 238-247
- Improved outcome based on fluid management in critically ill patients requiring pulmonary artery catheterisation.Am Rev Respir Dis. 1992; 145: 990-998
- Algorithms, guidelines and protocols: Can they really improve what we do?.Transfusion. 1994; 34: 281-282
- Diuretic efficacy of high dose furosemide in severe heart failure: Bolus injection versus continuous infusion.J Am Coll Cardiol. 1996; 28: 376-382
Article info
Publication history
Published online: February 14, 2018
Identification
Copyright
© 2018 Elsevier Inc. All rights reserved.
